Is healthcare racist?

In this episode, Ferdouse speaks to Shoba Poduval about health inequalities among ethnic minorities – including childbirth and mental health treatment – and wonders how digital technology could help the situation. 

About Shoba Poduval

Shoba is a GP and clinical academic in UCL’s eHealth unit where she spends her time developing and evaluating digital health services. 

Shoba has recently completed a secondment at the Office for Health Improvement and Disparities, London region - a part of the Department of Health and Social Care - where she undertook research to support the development of a strategic framework for addressing ethnic health inequalities through an anti-racist health lens.

Transcript

Ferdouse Akhter  0:05   

Hello and welcome to Health in a Handbasket, your podcast about the sexy world of Healthcare Engineering. I'm Ferdouse Akhter, and I'll be your host. I'm the marketing and Community Manager at UCL Institute of Healthcare Engineering. And although I don't always understand what's written in the research papers published by academics, I know that what we're doing in the world of healthcare engineering is important and impactful. And I want to share that with you by speaking to those who know a bit more about him than me. 

From today's handbasket, we're picking out the topic of racism in healthcare. It’s a heavy topic. And as a brown woman, I of course have a vested interest. You might be thinking, racism in healthcare, does it even exist? We’re brought up to believe that healthcare and the NHS is there for us when we need it. hich it is. But there seems to be caveats to how effective the treatment is, depending on the colour of your skin. And that's something we're going to be exploring today. I'm here with Shoba Poduval. Hi Shoba. She's a GP and a lecturer at UCL's eHealth unit, which exists to help people get better through digital health promotion and disease management programmes. We'll get into the work she does to help people get digitally savvy, but more on that later. So hi, Shoba. Let's start with the issue. What problem are we facing in healthcare? 

Shoba Poduval  1:28   

The issue that I'm looking at the moment is to do with inequalities in health in people who are from ethnic minority backgrounds, and digging deeper into what is causing those inequalities, in particular, the issue of racism, so the experience of racism and how that impacts on health. 

Ferdouse Akhter  1:47   

It's a big issue. So where did your passion for this come from?  

Shoba Poduval  1:51   

So I started researching this topic, actually due to a policy secondment that I've been doing since December, I've just finished actually working with the Office for Health Improvement and Disparities in London, which is an office which is part of the Department of Health. And they've been working with a number of different agencies, including the Greater London Authority, the NHS, obviously, and a number of other organisations to try and tackle this problem of racism and health care. And this has all come about really as a result of COVID and how that highlighted the issue with disparities and health between the white population and ethnic minority populations. So we know that COVID outcomes were particularly poor, for people from ethnic minority backgrounds, mortality and morbidity were worse for people from ethnic minority backgrounds during COVID. And that really brought this issue to the forefront. Even though we've known for a long time, over sort of 20-30 years, there's been data to show that health outcomes in ethnic minority communities are worse. COVID and a number of other kind of social issues and the Black Lives Matter movement has brought it to the forefront as well. And I think we're now in an era where people are kind of finally ready to talk about this issue. And also aware that we need to start acting on the issue rather than talking about it and, understanding the issue, we need to do something about it as well. 

Ferdouse Akhter  3:16   

So you mentioned you work for the Office of Health Improvement and Disparities, why do you think we need anti-racist policies in healthcare then? 

Shoba Poduval  3:23   

So we think the reason why we need to specifically look at anti-racism is that that's the perspective we need to take if we really want to tackle this problem, a sort of softly-softly approach where we kind of make small changes to the way we provide services probably isn't going to be as effective. We really need to understand what people's experiences of racism and healthcare are and take an anti-racist approach to that. Which means really kind of understanding the perspective of the service user and their experience, their experiences of trauma, or the bad experiences of health care, tailoring the services that we're offering to meet the needs of that service user and their community and that population.  

So it's much more than just being culturally tailored, which, you know, that kind of term comes up a lot in research on ethnic minority health. Culturally tailored means understanding the culture of the person that you're looking after, which is really important, because culture can affect so many health behaviours, and so many health attitudes and so much health knowledge. So if we take for example, diabetes, so much of that is dependent on the diet that you eat, and so that your diet is dependent on the culture that you come from.  

So I think taking an anti-racist approach is a step further than that, where not only are we understanding the culture for understanding adverse experiences and adverse processes context that people are having to go through. So we're talking about socio economics as well. What are the kind of life's challenges that people have had to go through, which have adversely impacted their health as well. So we know that things like education, employment, income, all of those things affect your health. And ethnic minority communities are more likely to have adverse experiences of those things as well. So there's a lot of interconnection between all those different factors and taking an anti-racist approach is about incorporating all of those different aspects in the way that you care for people. 

Ferdouse Akhter  5:25   

So I guess that's why it's important that government gets involved. Because it's such a huge issue in terms of like, education, socioeconomics, all of that stuff. 

Shoba Poduval  5:35   

Absolutely. So, in public health, we talk about kind of upstream versus downstream responses and interventions. And this is definitely one area where we need both of those things happening. So as well, as...you know, my focus is on health care and health services and how we can improve those and take an anti-racist approach to those things. But equally, and maybe more importantly, we need the social and economic policy that's going to improve people's life chances so that those things don't negatively impact their health as well.  

Ferdouse Akhter  6:08   

What are some of the specific issues we're facing then? 

Shoba Poduval  6:11   

So, some of the starkest inequalities that we're seeing are in things like maternity care, where we now know that black women are five times more likely to die in childbirth than white women. Yeah, it's really shocking. 

Ferdouse Akhter  6:26   

From child birth, something that's meant to be like, you know, you go to the hospital, and you come out with a baby. 

Shoba Poduval  6:32   

Something that's supposed to be a really kind of happy celebration, and it is for so many women. But what as a mother, this really affects me too...what I think brown black women now have to contend with is not only you know, all the feelings that come along with pregnancy, but also knowing that fact and knowing that you're more likely to have an adverse outcome and to even die through, you know, something that should be a really normal part of life, I think is really terrifying. 

Yeah, I think I think it's just a huge wake up call for a lot of people. And it should be particularly to maternity services, which we know in the UK at the moment is massively under resourced, and then there's huge issues there. But I think this is one of the really, really important issues that that we need to deal with as a priority. And then there's the way that black women or a woman from minority ethnic cultures and backgrounds are treated is different to the way that white women are treated. And that might perhaps be because healthcare staff a list used to dealing with women from ethnic minority backgrounds or don't understand the culture as well, or due to, you know, implicit bias. So biases that we have in our subconscious that we allow to make decisions for us, but actually are putting people at higher risk than others. So I mean, that's one of the things that we'll we kind of looked at as part of my research with the Office for Health Improvement Disparities is around the workforce and making sure that the healthcare workforce reflects the patient population that we're seeing. So making sure it's diverse, and there's people from different cultures working within the NHS workforce, and also making sure that we provide cultural diversity training. So providing training to the workforce, both white and non-white about different cultures and treating people from different cultures and, and you know, the right ways and the best ways of doing that, to avoid bias and to avoid treating people differently. So those are some really important interventions that are already happening, you know, number of trusts and care institutions are already doing this, but it needs to become more widespread and just a normal part of NHS culture as well. 

Ferdouse Akhter  8:42   

And what are some of the other issues we're facing? 

Shoba Poduval  8:45   

Some of the other important issues are in mental health. So we know that black men in particular have poorer outcomes from mental health problems, are more likely to be admitted to hospital. And that could be a number for a number of reasons. They can present to health services later. And that might be due to problems with stigma around talking about mental health or seeking help for mental health problems. It can also be not just within the black community within the Asian community is what can be different ideas around how mental health problems should be treated, when to seek help, what kind of help to see and also problems with the way that ethnic minority communities are treated within healthcare. So we know that again, mental health is another area within healthcare, which is massively under resourced, and we don't have...so I talked about culturally tailoring previously, we don't have those culturally tailored mental health services. So for example, in my own practice, as a GP, when I'm referring patients from for example, a Turkish background or Bangladeshi background to counselling, I always try and find local organisations which are for example, Turkish women's organisations who have dedicated counsellors who come from In the same background from that community, because I know that that patient is going to have much better...a much better experience much better outcomes from talking to someone within their community who understands the culture, and the ways that even the simple things like the language, the words that you use to describe your feelings are different in one culture versus another. We did a student project on this recently, we did a systematic review, looking at how South Asian women present to primary care. And the language that they use just to describe how they're feeling is completely different. And they might use language to describe how they feel in a physical way. But what they actually mean is, it's a mental health issue, but they don't have the language to, to describe how they're feeling mentally and emotionally. And that takes a lot of experience, both as a clinician, and a sensitivity to the communities that you're working with. And I've been doing this for long enough that I can kind of do that now. But I think it's really important that we highlight those issues, and that we provide the right training for clinicians and provide the right services also, so that we can deal with those problems adequately. 

Ferdouse Akhter  11:06   

That's super interesting about language, because I’m Bangladeshi, and in my, like you said, in my culture, I don't think we've ever talked about mental health. I, when I think about my about my mother tongue, I can't think of a way to say I am mentally going through something, because I don't think the words exist, the issues might exist. But then again, like, people don't think about mental health in that way. It's kind of like brushed under the carpet, or it's seen as like, I don't know, some Islamic djin or something like that, which is, you know, it's just people trying to find an answer to a problem, right? 

Shoba Poduval  11:42   

Yeah, I think there's so many different perspectives on this, depending on which culture you're talking about. And I think one of the big problems in ethnic minority cultures is the stigma and the taboo around mental health, because it's not commonly talked about. And it's the same in, you know, white western cultures until very recently, as well. But I think particularly a problem with ethnic minority communities. And so that makes it very difficult, I think, for patients to present and to talk about their problems early at a stage where, you know, we can intervene early and provide the right support early. And I think it can make it difficult to access the right kind of help and treatment as well, if someone's kind of unable to talk about their feelings in an effective way, or the clinician is unable to kind of assess exactly what's going on, clearly. So I think, yeah, language is a huge problem. And it this, this happens in a number of different areas, not just in mental health. So I read recently that even the word for menopause, and other words in women's health doesn't exist in other languages. So for example, in Urdu, the word that's used actually means barren, which, you know, has its own connotations and negative implications with regard to menopause. So, yeah, I think it's really important to be sensitive to that and be aware of that within healthcare.  

Ferdouse Akhter  13:12   

You're a GP and a digital health researcher. So do you think tech is a solution to this problem? 

Shoba Poduval  13:19   

I think it has the potential to help with a number of issues. But I think that we also need to acknowledge that there is the potential for worsening inequalities as well, if if tech isn't developed and used in the right way. So what I mean is, we know that health tech has a number of advantages in terms of patient care. So particularly when we talk about self management, for example, in diabetes, which is one area that I've done a lot of research in, and I'm researching gestational diabetes at the moment. So talking to women from very diverse cultures, like diabetes and prediabetes during pregnancy. Yeah. And women from African Caribbean and South Asian populations are at higher risk of both type two diabetes and diabetes in pregnancy. 

Ferdouse Akhter  14:08   

Is gestational diabetes when when you get pregnant? , 

Shoba Poduval  14:11   

Yeah so when you're pregnant, your hormones change, and that affects another one of your hormones called insulin. And if you have diabetes and pregnancy, you then become higher risk of having type two diabetes after pregnancy and later on in life as well. And it can also adversely affect the child as well. So it's a huge issue. And one of the findings from our research has been that women would welcome additional support. So an app which helps with dietary and meal guidance, for example, because it is the management and the mainstay of the management is about diet. So eating the right quantities of rice, bread, potatoes versus vegetables, fruit, that kind of thing. And in the NHS, we actually do a pretty bad job of giving that advice because we don't have the time the resource to provide really detailed individualised support to women and people who have diabetes in general. And so that's where digital solutions, I think come in really handy because they can provide that individualised support where it's handheld, you can access at any time, you can input your own data, it can respond to your individual data and provide you with really useful advice at any time. And you can connect with other people as well, there's so many advantages, but one of the risks is that people from ethnic minorities, particularly those who have less English or less education, or less access to technology, so you need really simple things like Wi Fi and a smartphone to be able to access any of this and not everyone has that for a start. And also, if you have trouble with language, you're going to have real problems accessing and using any of this technology too. So those are all things that we need to think about when we're developing and implementing this kind of technologies is taking those people into account and designing the technology and, and delivering it in a way that makes it much more accessible. And that's already happening. We're seeing a lot of local councils and voluntary organisations, giving people free access to Wi Fi, sharing devices, making devices more accessible through libraries and a number of different schemes. So that's all happening. And in a way that's quite straightforward problem to solve if given enough resource, but I think the less straightforward problem is people's interest and motivation, and trust in using digital technology as well. So we also know that people from ethnic minority backgrounds are a lot less trusting with regard to health care institutions in general, but particularly with regard to sharing data and showing ethnicity data. And that's been a huge problem in terms of measuring and understanding inequalities, because if we don't have that data on ethnicity, we can't then look at the differences that we're seeing. So I think there's a number of other obstacles that we need to explore and address before we can really see the benefits of technology in the general population. And that's what I'm really interested in finding out more about and whether there is a solution or you know, whether we need to be telling everyone to use digital technology, or if we we just accept that everyone needs to have options. And we need to have both non digital and digital options and be able to understand what people's preferences are and cater to their needs. I think that's a that's a really important idea that we need to accept as healthcare providers is that even if the policy priority might be to digitalise, and even if it seems like it's going to save us money, if our patients aren't necessarily on board with that, or it doesn't fit with their lifestyle, or it doesn't... they can't use it effectively for themselves. And we need to accept that it's not going to work for everyone. 

Ferdouse Akhter  17:53   

I think like when I think about like my mum's generation, she wouldn't like an app. Like she would want to go to the doctor who she knows on, like a name basis, and she would want to talk to the doctor. But I read something, I think you mentioned it, about how there's going to be like digital hubs. So you kind of like it's not just an issue about race, it’s like with everyone isn't it, like it's a generational thing, like having people who can access digital tech, because that's where the world is going. Yeah, but there's gonna be hubs to kind of bring that together. 

Shoba Poduval  18:22   

Yeah, so that's what I'm researching at the moment. So the evidence suggests that the groups of people who are more likely to be digitally excluded, so more likely to be able to use and make the most of digital technology are people who are older. And we will see this with our own families and grandparents, people who have less education, less income, and people have less English. So I'm really interested in in what we do about that. So at the moment, I'm doing a research project working with 100% Digital Leeds, who are a council funded organisation, working across Leeds, to deliver digital inclusion programmes, so programmes that give people access skills, and address this issue around motivation, interest, etc. And they specifically have set up a network of digital health hubs, which GPS and other healthcare providers can refer patients to, to access support from staff and volunteers who work within local voluntary organisations. So these are places that are set up in community centres, places where people tend to go for support for other things like benefits and food banks, that kind of thing anyway. So I'm looking at how these digital health hubs work. What are the sort of vital ingredients that they provide that help people to access health care and improve their health? How could they be improved? How could they be scaled up? How can we do this, you know, across the country, potentially if it's a potential solution to the problem? And it's yeah, we've just started doing the research but it's been really interesting so far, and one of the things that's come up so far, it's very early days, is that people you can't make people go from being digitally excluded to using digital health technology in one step, you need to bring them on gradually. And you need to get people online generally first. So using technology that may have nothing to do with healthcare first that interests them. And once they're onboard digitally, then you can talk to them about all these other things that digital can provide them, whether that's health care, or access to benefits, job applications, education and training, all those other things. We know there's so many benefits. So there are some really vital key ingredients there that we're going to be identifying and highlighting and writing about. So hopefully, you'll hear more about that. 

Ferdouse Akhter  20:47   

I guess, at the moment, is just a hub in Leeds? 

Shoba Poduval  20:51   

There's multiple, there's a network in South Leeds, which is the most deprived area of Leeds, and it's a few of them that have been set up so far. But the plan is to upscale and then broaden that programme out further across Leeds. 

Ferdouse Akhter  21:05   

I think it sounds like an amazing programme. I mean, yeah, if I think about the people in my family and stuff like they would seriously benefit from something like that. 

Shoba Poduval  21:13   

Yeah, I think it's a really, really nice solution. But it requires investment and staff and people's time, sustained over a period of time as well. So it really it requires buy in, not just from national government, but also from local government as well to set up their own programmes locally. And we're seeing that happen. I mean, national government have been talking about digital solutions since COVID. It's been such a priority since then, when a number of local governments have tried to set up schemes like this. So we know that parts of London, Newham for example, have done some great work on digital inclusion. And I've worked with digital health hubs there. Manchester, also really interested in this topic and have set up or are setting up digital health hubs there as well. So it's slowly happening in pockets of different areas across the country, but we want to see this happen nationally, which should be sort of just a part of like the offer when it comes to healthcare, if we're going to move healthcare towards being digitised, then we need to be offering people the support to be able to access that as well. 

Ferdouse Akhter  22:19   

Definitely. I don't think trust and or mistrust is specifically ethnic minority thing.  

Shoba Poduval  22:26   

It's not but it is particularly bad in ethnic minority communities. And we know that from things... so I just did a study on COVID vaccine hesitancy, for example, and trust in government and healthcare institutions was such a big problem with the COVID vaccine. And the reason why people from ethnic minor who didn't want to take it. And so that kind of highlighted that whole issue. And one of the things that people told me when I was just talking about the vaccine was when people... when you were vaccinated, you were asked your ethnicity for data collection purposes. And a number of my participants said, Why are you asking me about my ethnicity? Why do you need that data, I'm not gonna give you that data. I never give anyone my ethnicity data. There's just this unwillingness to share it. And I think there's a mistrust in why the data is collected, where it goes. 

Ferdouse Akhter  23:17   

But it's like, I might be penalised for it. And that's why yeah, people don't want to share their data. 

Shoba Poduval  23:21   

Yeah. And that all comes from historic injustice, historic trauma, historic racism, that all comes from things that have happened in the past where black and ethnic minority people have been treated differently. So it's, it's rooted in those systems, and then that inequality. And so I think we need to acknowledge that in a number of different areas, including data. And data is so important, because if we don't have good data, we can't measure anything, we don't know where we are, we can't assess where we're at where the inequalities are, and what we need to do about. And that's our starting point, for me being able to do anything else. So it's a really important issue. 

Ferdouse Akhter  23:59   

There's a lot of reservations about giving your data away. And I guess with something like an app that would come into play, I remember reading stuff about the NHS selling their data and... 

Shoba Poduval  24:10   

So we're really happy to use, like Instagram and Tiktok, and whatever, where you have to input your data, and it's collecting data on you all the time. Because it's watching what you're accessing. And the the algorithms are providing the content based on what you're accessing. And we're totally fine with that. But then when it comes to health care, people become a lot more, they do become a lot more twitchy about it. And I think that like health, the tech industry kind of has to learn from that not in terms of we should be more like Facebook and just like, trick people into giving us data but like, why is it that people are so okay with using apps for one thing, but not for health? Like I think we need to understand that a bit more and understand... Yeah, I don't know. I think there's some differences there in the way that people use technology. 

Ferdouse Akhter  25:01   

Yeah, it's true because like, even on Instagram, they ask me health related questions. I'm like, yeah, take it. But then... 

Shoba Poduval  25:09   

But then if you had if the NHS app was asking you a look, would you still be fine? 

Ferdouse Akhter  25:12   

Yeah, I went on NHS I gave them everything... 

Ferdouse Akhter  25:28   

I know. Because like, I was at the library the other day is literally the library. I feel like it's the safest place ever. And there was...there was a lady having an argument with a librarian, and I was already having an argument, the library about how they have her date of birth in the register. And he was like, we kind of need it because like, there's some 18-related content, and we can't let you take that out and all of that stuff. And so we having your date of birth, mitigates that kind of thing? And she was like, no, no, no, all of that stuff, argument about it. And then he was like, you can just take it off. But it means that every time you take out, you know, sensitive content, I have to check your ID and stuff. She's like, yeah. And I was like, but people have like such a, I don't know.  

Shoba Poduval  26:04   

Yeah, people have an aversion to sharing personal data with particular organisations, I feel like, I feel like social media gets away with it somehow, where it just like, makes you feel like it's okay to share your data. And people do it. 

Ferdouse Akhter  26:17   

Like the library is part of the council and the council has your data. It's like, you're on the on the electoral roll, you get posted all the time. So is yeah, it didn't make sense to me.  

Shoba Poduval  26:28   

It doesn't make sense. Yeah, I think we need to understand it better. 

Ferdouse Akhter  26:41   

If you had all the power in England? What would you do with that power? How would you solve this issue? 

Shoba Poduval  26:47   

Um, that's a big question. 

Ferdouse Akhter  26:50   

A lot of power as well!  

Shoba Poduval  26:52   

I think I already kind of do this. But I, I would put more emphasis and more focus on the people who are most disadvantaged. So people who are in the most difficult situations socio economically, in terms of their health, we know those things are linked, in terms of racism through those things are linked. So I would put more resource and target my policy towards improving the lives of those people. Because I think if we can do that, I mean, not only are we going to improve life expectancy, not only are we going to improve the health of those people, we’ll improve the workforce will improve the burden on the health system will improve the economic growth of the country, and people will be happier, and there will be more equality. And that's that I think, is really, really important in terms of, you know, where we want our society to be headed, and how we want the next generation to experience things as well. And  we know that disadvantage, is inherited across generations. And if we want to improve the lives of future generations, we need to start by improving the lives of our current population.   

Ferdouse Akhter  28:02   

I feel like with something like this, especially with the issue of race, it's like you feel like you're a small fish in a big pond. So what would you say to someone who's interested in this field? Because I feel like even if we are small fish, you're doing a lot of great work to make a big ripple.  

Shoba Poduval  28:19   

Yeah, you're right, you can often feel like a small fish in a big pond when you're dealing with, you know, these challenges are huge social health challenges. But I think it's also really rewarding work. It's really, if you're someone like me, who's very kind of values led in terms of what you do, and you get your satisfaction and your enjoyment and your joy, from doing things that sit close to your values, and working with communities that you really care about on issues that you really care about. It's such fulfilling work. And I also think, you know, just doing your bit is really important. So I've used this analogy before of like, you might not be able to build the entire house. But if you can put one brick in the wall, you've contributed to building that house, and everyone needs to put their bricks in, if we're all going to build the house. And I think that's, that's a really important analogy to think about with this issue. Because because it's not just gonna take one person to change things. It takes everyone doing their bit and it's everyone's problem. And I think that's another way of looking at it as well.   

Ferdouse Akhter  29:23   

I think that's also a good way to end things. One brick at a time. Yes, absolutely. We can make change. Definitely. So thank you for speaking to us today Shoba. 

Shoba Poduval  29:31   

Thank you. 

Ferdouse Akhter  29:36   

Health in a Handbasket is produced by UCL Institute of Healthcare Engineering and edited by Cerys Bradley. The Institute of Healthcare Engineering brings together leading researchers to develop the tools and devices that will make your life better. We’re using this podcast to share all their amazing work taking place. You can learn more by searching UCL Health in a Handbasket or following the link in the show notes to share with your friends and family if you found this interesting, where available everywhere especially where you just listened to us.